Use Of Inotropes Research Articles

Guide to Temporary Mechanical Support in Cardiogenic Shock: Choosing Wisely.

Cardiogenic shock is a multisystem pathology that carries a high mortality rate, and initial pharmacotherapies include the use of vasopressors and inotropes. These agents can increase myocardial oxygen consumption and decrease tissue perfusion that can oftentimes result in a state of refractory cardiogenic shock for which temporary mechanical circulatory support can be considered. Numerous support devices are available, each with its own hemodynamic blueprint. Defining a patient's hemodynamic profile and understanding the phenotype of cardiogenic shock is important in device selection. Careful patient selection incorporating a multidisciplinary team approach should be utilized.

Clinical effects of major aortopulmonary collateral arteries in term neonates diagnosed with transposition of the great arteries.

Transposition of the great arteries is a severe CHD that affects term neonates. The presence of major aortopulmonary collateral arteries in neonatal transposition of the great arteries patients is rare. This study investigated the clinical and haemodynamic implications of the presence of major aortopulmonary collateral arteries in neonatal transposition of the great arteries patients who underwent an arterial switch operation. The study was a retrospective analysis conducted on neonates diagnosed with transposition of the great arteries who underwent arterial switch operation within the period from 1 May 2020 to 1 January 2023 at two high-patient-volume paediatric cardiac surgery centres in Turkey. The patients' demographic characteristics, echocardiographic features, and clinical data were analysed. Additionally, the possible clinical effects of the presence of major aortopulmonary collateral arteries were statistically evaluated. Two hundred cases of neonatal transposition of the great arteries were included in this study, with 55% of the cases male. All the patients underwent arterial switch operation. The median age at the time of arterial switch operation was 5 days (interquartile range 3-7), with a median weight of 3,100 g (interquartile range 2,900-3,400). The median pre-operative saturation level was 76% (interquartile range 70-82%). Prior to arterial switch operation, 32 patients underwent balloon atrial septostomy.In all the patients, the interatrial septum was checked to determine if the atrial septum was intact. A patent foramen ovale (≤ 3 mm) was found in 112 patients, and a non-restrictive atrial septal defect (> 3 mm) was found in 88. Forty-eight patients had ventricular septal defects, and 72 had coronary anomalies. Major aortopulmonary collateral arteries were found in 4 patients pre-operatively and in 12 patients after arterial switch operation (echocardiography, n = 8; angiography, n = 4). Of the patients with post-operative detection of cumulative number of major aortopulmonary collateral arteries were on post-operative day 1 in 2 patients, on post-operative day 3 in 5 patients, on post-operative day 7 in 6 patients, and on post-operative day 14 in 11 patients.Transcatheter closure was performed in 3 cases due to recurrent extubation failure. Major aortopulmonary collateral artery shrinkage was observed in one case under medical treatment. The length of paediatric cardiac intensive care unit stay (10 days versus 8 days; p < 0.005), mechanical ventilator time (4 days versus 2 days; p = 0.02), and inotrope use time (5 days versus 3 days; p = 0.04) were higher in the major aortopulmonary collateral artery cases than patients without major aortopulmonary collateral artery. Major aortopulmonary collateral arteries are frequent in transposition of the great arteries patients and may have clinical effects. The presence of major aortopulmonary collateral arteries should be investigated in patients who do not have a favourable post-operative course after arterial switch operation.

Postoperative Pulmonary Artery Pulsatility Index Improves Prediction of Right Ventricular Failure After Left Ventricular Assist Device Implantation

This study evaluated whether the postoperative pulmonary artery pulsatility index (PAPi) is associated with postoperative right ventricular dysfunction after durable left ventricular assist device (LVAD) implantation. Single-center retrospective observational cohort study. The University of Kansas Medical Center, a tertiary-care academic medical center. Sixty-seven adult patients who underwent durable LVAD implantation between 2017 and 2019. All patients underwent open cardiac surgery with cardiopulmonary bypass under general anesthesia with pulmonary artery catheter insertion. Clinical and hemodynamic data were collected before and after surgery. The Michigan right ventricular failure risk score and the European Registry for Patients with Mechanical Circulatory Support score were calculated for each patient. The primary outcome was right ventricular failure, defined as a composite of right ventricular mechanical circulatory support, inhaled pulmonary vasodilator therapy for 48 hours or greater, or inotrope use for 14 days or greater or at discharge. Thirty percent of this cohort (n=20) met the primary outcome. Preoperative transpulmonary gradient (odds ratio [OR] 1.15, 95% CI 1.02-1.28), cardiac index (OR 0.83, 95% CI 0.71-0.98), and postoperative PAPi (OR 0.85, 95% CI 0.75-0.97) were the only hemodynamic variables associated with the primary outcome. The addition of postoperative PAPi was associated with improvement in the predictive model performance of the Michigan score (area under the receiver operating characteristic curve 0.73 v 0.56, p=0.03). An optimal cutoff point for postoperative PAPi of 1.56 was found. The inclusion of postoperative PAPi offers more robust predictive power for right ventricular failure in patients undergoing durable LVAD implantation, compared with the use of existing risk scores alone.

Strong Association between Inotrope Administration and Intraventricular Hemorrhage, Gestational Age, and the Use of Fentanyl in Very Low Gestational Age Infants: A Retrospective Study.

This was a single center, retrospective cohort study designed to evaluate the association between the administration of inotropes to hypotensive very low gestational age infants (VLGAI) and prenatal and neonatal risk factors. Inpatient medical records were reviewed to identify neonates treated with inotropes (treated group) and a control group for comparison. Two hundred and twenty two (222) VLGAI (less than 32 weeks' gestation) were included in the final analysis and were stratified based on timing of treatment with 83 infants (37.4%) and 139 infants (62.6%) in the treated and control groups, respectively. A total of 56/83 (67%) received inotropes for arterial hypotension during the first 3 days (early treatment subgroup) and 27/83 (32.5%) after 3 days of life (late-treated subgroup). Fentanyl, severe intraventricular hemorrhage (IVH), and gestational age (GA) were the risk factors most significantly associated with the need for inotrope use both during the first 3 days of life and the whole NICU stay, before and after adjustment for confounders. In conclusion, fentanyl, severe IVH, and GA are the risk factors most strongly associated with the need for inotrope treatment in VLGAI. Measures to modify these risk factors may decrease the need for cardiovascular medications and improve outcomes.

Five-year Outcomes of Transcatheter Edge-to-Edge Repair in Patients with Mitral Regurgitation and Cardiogenic Shock

Objective: To analyze five-year clinical and echocardiographic outcomes in patients presenting with acute cardiogenic shock (CS) who underwent transcatheter edge-to-edge repair (TEER) for moderate or severe mitral valve regurgitation (MR). Methods: All consecutive patients who underwent TEER for MR were identified from our institutional medical records between 2015 and 2022. Patients presenting with CS undergoing TEER were included in the primary analysis. MR was diagnosed based on patient's echocardiographic findings and CS was diagnosed according to the definition in the TVT registry and/or presence of inotrope use prior to procedure and/or mechanical circulatory support prior to procedure. Kaplan-Meier survival curves were constructed to analyze outcomes. Primary outcome was five-year incidence of all-cause death. Secondary outcomes were major adverse cardiovascular and cerebrovascular events (MACCE) and readmission for heart failure (HF). Results: A total of 35 patients were included in the study. Mean age was 81±10.4 years and 16 patients (45.7%) were male. Mean STS-score was 10.2±7.1. Nine (25.7%) patients had prior myocardial infarction (MI), 22 (62.8%) had previous atrial fibrillation, while 9 (25.7%) patients were hospitalized for HF within the past year. MR etiology was degenerative (71.4%), functional (22.9%), and mixed (5.7%). Prior to presentation with CS, NYHA classification included 2 (5,7%) patients in class I, 6 (17.1%) in class II, 13 (37.1%) in class III, and 14 (40%) in class IV. Pre-procedural mean LVEF was 56.4 ± 13%. Procedural characteristics included mean procedural time (from access to guide removal) of 2.0 ± 0.6 hours, &gt; 1 implanted device in 14 (40.0%) patients, 1 patient had a single leaflet attachment. There was no procedural device embolism, device thrombosis, conversion to sternotomy, life threatening bleeding, stroke, MI, or death. Mean postoperative length of stay was 5.1 ± 4.4 days. During their hospital stay, a transient ischemic attack event occurred in 1 patient; however, no MI, stroke, or death were observed in any patient. During the follow-up, 13 (37.1%) patients were readmitted for HF, 1 patient needed mitral valve replacement and 1 patient needed new TEER. At 5 years, only 4 (11.4%) patients were alive. Conclusion: Despite excellent procedural and early outcomes for patients with significant MR and CS undergoing TEER, poor survival was observed after 5 years, which may be related to advanced age of this cohort.

68 Multimodal Monitoring of Hemodynamics in Extremely Low Birth Weight Preterm Infants in a Canadian Tertiary Level Unit: Non-Blinded Randomized Control Trial/MUSE Trial

Abstract Introduction/Background Current approaches for the evaluation and treatment of transitional circulatory issues in preterm infants based primarily on blood pressure (BP) may be harmful. It is essential that these approaches are adequately investigated. This study tests a detailed hemodynamic approach with a multimodal assessment compared to standard approach, using a Vasoactive Ventilation Renal score (VVR) that incorporates inotrope use, ventilation support, and renal function along with inotrope use reflecting cardiorespiratory-renal health. Objectives To determine whether multimodal hemodynamic monitoring will improve cardiorespiratory-renal health as evidenced by decreasing VVR in preterm infants at one week of life. Design/Methods This was a randomized control trial of preterm infants born &amp;lt;29 weeks gestational age who were admitted to a tertiary neonatal intensive care unit between 15 Feb 2019 and 31 Dec 2021. Eligible infants were randomly assigned for the first 72 hours of life to either a multimodal assessment arm (consisting of early targeted neonatal echocardiogram, continuous cerebral near infrared spectroscopy [NIRS] and clinical-biochemical data) or to a standard arm (using clinical-biochemical data only). A comprehensive study guideline was used for hemodynamic assessment in the multimodal arm. Univariate and multivariate analyses compared the two arms. Results 298 infants were screened during the study period and 147 were randomly assigned (75 multimodal arm, 72 standard arm). 68 in the multimodal and 64 in the standard arm were included in the preliminary analysis (Figure 1). Baseline characteristics were similar in both arms (Table 1). The mean VVR scores within 7 days of life were 16.5(SD 15.4) and 18.9(SD 20.2) in the multimodal and standard arm respectively (p=0.451). Mean Ventilation Index scores in the first 72 hours of life were 16.2(SD 15.7) and 17.9(SD 15.5) respectively (p=0.552, Table 1). Peak VVR scores &amp;gt;53 at 7 days were significantly higher in the standard arm (11.1%) than in the multimodal arm (0%), p= 0.005. Outcomes of death, severe intraventricular hemorrhage and length of hospital stay were not statistically different. However, there was a trend toward decreased inotrope use in the multimodal arm compared with the standard arm (16.2% vs. 23.4% respectively, p=0.294). Conclusion In preterm infants, multimodal hemodynamic assessment during the transitional period was not associated with decreased VVR scores that signify improved cardiorespiratory-renal health, but led to lower incidence of VVR score greater than 90th centile and a decreasing trend in inotrope use in the first week of life.

Dengue Fever Presenting As Acute Febrile Illness In Neonates: A Case Series From Pakistant.

Dengue fever is a mosquito-borne disease caused by flavivirus. It primarily infects people living in tropical and subtropical areas and can be transmitted vertically or horizontally to new-borns. We discuss the clinical spectrum, treatment, and outcomes of five neonates who presented with dengue fever at Aga Khan Hospital for Women in Karimabad, Karachi, Pakistan, during the 2021 post- monsoon season (October to December). Dengue infection was confirmed via positive NS1 antigen test. All new-borns had fever, flushing, and thrombocytopenia. Capillary leak syndrome and haemorrhagic complications occurred in one case. Two babies required oxygen support, with one mortality. Due to the severity of the disease in this population, we suggest that dengue fever should be evaluated as a differential diagnosis in neonates with sepsis and thrombocytopenia, especially in high-risk or endemic areas. Critical management strategies for neonatal dengue fever are the same as those for other paediatric patients and include judicious use of intravenous fluids and inotropes.

Pediatric sepsis profile in a tertiary-care hospital in Indonesia: a 4-year retrospective study.

This study aimed to explore the factors contributing to mortality and its management among pediatric sepsis patients at a single center in Indonesia. We conducted a retrospective study of children admitted due to sepsis from January 2015 to December 2019 in an Indonesian tertiary hospital. The mortality rate of pediatric sepsis in our study was 76.1% among 176 records with outcome identified. Mortality was significantly associated with septic shock at triage, number of organ failure, intensive care unit admission, inotropic use, septic shock and severe sepsis during hospitalization. Timing of antibiotic use did not affect mortality. Death within the first 24 h occurred in 41.8% of subjects, mostly due to septic shock. This study illuminates the current state of pediatric sepsis management in our Indonesian hospital, revealing it as inadequate. Findings highlight the need for improved pre-hospital systems and sepsis recognition tools, and wider use of mechanical ventilators and advanced monitoring due to limited pediatric intensive care unit beds. Future research should focus on hospital-specific sepsis protocols to reduce pediatric sepsis mortality rates.

Management of Sepsis and Septic Shock: What Have We Learned in the Last Two Decades?

Sepsis is a clinical syndrome encompassing physiologic and biological abnormalities caused by a dysregulated host response to infection. Sepsis progression into septic shock is associated with a dramatic increase in mortality, hence the importance of early identification and treatment. Over the last two decades, the definition of sepsis has evolved to improve early sepsis recognition and screening, standardize the terms used to describe sepsis and highlight its association with organ dysfunction and higher mortality. The early 2000s witnessed the birth of early goal-directed therapy (EGDT), which showed a dramatic reduction in mortality leading to its wide adoption, and the surviving sepsis campaign (SSC), which has been instrumental in developing and updating sepsis guidelines over the last 20 years. Outside of early fluid resuscitation and antibiotic therapy, sepsis management has transitioned to a less aggressive approach over the last few years, shying away from routine mixed venous oxygen saturation and central venous pressure monitoring and excessive fluids resuscitation, inotropes use, and red blood cell transfusions. Peripheral vasopressor use was deemed safe and is rising, and resuscitation with balanced crystalloids and a restrictive fluid strategy was explored. This review will address some of sepsis management's most important yet controversial components and summarize the available evidence from the last two decades.

Incidence of Acute Kidney Injury in 1 - 14 years old Critically ill Children in a Tertiary care Center

Introduction:Acute Kidney injury (AKI) is associated with poor outcomes in critically ill hospitalized children. There are very few studies on incidence of AKI based on urine output criteria of KDIGO (Kidney Disease: Improving Global Outcome) and time lag between the fall in urine output and rise in serum creatinine. This study was therefore aimed at determining the same.&#x0D; Methods: A prospective study was conducted in the Department of Paediatrics of a tertiary care hospital. 171 critically ill children between one to 14 years who were admitted in PICU were enrolled. Hourly urine output and eight hourly serum creatinine levels were measured and incidence of AKI was calculated along with lag time between fall in urine output and rise in serum creatinine. Outcome of children with AKI was also studied. Data analysis was done using SPSS software version 25.0 and Microsoft excel 2007.&#x0D; Results: The mean age + SD of children in the study was 5.5 years ± 3.76 with a range of one to 14 years, with 62.6 % of them being boys. The incidence of AKI in the study population was 14.62%. The mean lag time between fall in urine output and rise in serum creatinine was found to be 13.21 hours. AKI had a significant association with mortality, use of nephrotoxic drugs, inotropes and mechanical ventilation.&#x0D; Conclusions: A significant number of critically ill children develop AKI and its occurrence portends a poor outcome. Utilization of the KDIGO reduced urine output criteria as a marker of AKI allows for early detection and intervention

Subclinical cardiac dysfunction may impact on fluid and vasopressor administration during early resuscitation of septic shock

BackgroundAccording to the Surviving Sepsis Campaign (SSC) fluids and vasopressors are the mainstays of early resuscitation of septic shock while inotropes are indicated in case of tissue hypoperfusion refractory to fluids and vasopressors, suggesting severe cardiac dysfunction. However, septic cardiac disfunction encompasses a large spectrum of severities and may remain “subclinical” during early resuscitation. We hypothesized that “subclinical” cardiac dysfunction may nevertheless influence fluid and vasopressor administration during early resuscitation. We retrospectively reviewed prospectically collected data on fluids and vasoconstrictors administered outside the ICU in patients with septic shock resuscitated according to the SSC guidelines that had reached hemodynamic stability without the use of inotropes. All the patients were submitted to transpulmonary thermodilution (TPTD) hemodynamic monitoring at ICU entry. Subclinical cardiac dysfunction was defined as a TPTD-derived cardiac function index (CFI) ≤ 4.5 min−1.ResultsAt ICU admission, subclinical cardiac dysfunction was present in 17/40 patients (42%; CFI 3.6 ± 0.7 min−1 vs 6.6 ± 1.9 min−1; p < 0.01). Compared with patients with normal CFI, these patients had been resuscitate with more fluids (crystalloids 57 ± 10 vs 47 ± 9 ml/kg PBW; p < 0.01) and vasopressors (norepinephrine 0.65 ± 0.25 vs 0.43 ± 0.29 mcg/kg/min; p < 0.05). At ICU admission these patients had lower cardiac index (2.2 ± 0.6 vs 3.6 ± 0.9 L/min/m2, p < 0.01) and higher systemic vascular resistances (2721 ± 860 vs 1532 ± 480 dyn*s*cm−5/m2, p < 0.01).ConclusionsIn patients with septic shock resuscitated according to the SSC, we found that subclinical cardiac dysfunction may influence the approach to fluids and vasopressor administration during early resuscitation. Our data support the implementation of early, bedside assessment of cardiac function during early resuscitation of septic shock.

Access Site–Stratified Analysis of the Incidence, Predictors, and Outcomes of Impella-Supported Patients With Cardiogenic Shock

This study aimed to evaluate the incidence, predictors, and outcomes of Impella-assisted patients with cardiogenic shock, stratified by the access site-transaxillary (TX) or trans-subclavian (TS) versus the conventional transfemoral (TF) approach. For this study, we analyzed the cases entered into the Japanese Percutaneous Ventricular Assist Device registry between February 2020 and December 2021. A multivariable logistic regression analysis was conducted to calculate the adjusted odds ratio (aOR) and 95% confidence intervals (CIs) to identify the predictors of the TX/TS approach, with reference to those who received the conventional TF approach. A log-rank test was performed to compare the 30-day mortality between the 2 approaches. A total of 2,564 cases of Impella were included in the study, of which 167 (6.5%) were accessed by way of the TX/TS approach. TX/TS approach cases were younger and had a higher percentage of concomitant use of extracorporeal membrane oxygenation or an intra-aortic balloon pump. The predictors of the TX/TS approach included a presentation with the acute coronary syndrome (aOR 0.32, 95% CI 0.16 to 0.63, p <0.001), cardiac arrest (aOR 0.10, 95% CI 0.02 to 0.36, p=0.003), cardiogenic shock (aOR 0.51, 95% CI 0.33 to 0.79, p=0.002), and inotropic use (aOR 1.88, 95% CI 1.08 to 3.49, p=0.033). The 30-day mortality was comparable between TX/TS and TF approaches (29.3% vs 29.6%, respectively; log-rank, p=0.64). Our analysis revealed that approximately 6% of the Impella-assisted patients with cardiogenic shock received the TX/TS approach as their first access site. These results suggest that the TX/TS approach may be a viable alternative to the TF approach in certain patients requiring Impella support.

Patient mobilization in the intensive care unit: Assessing practice behavior – A multi-center point prevalence study

ObjectivesTo describe intensive care unit mobility clinical practice behaviors and the factors associated with these behaviors that could explain the theory–practice gap. MethodologyA multi-center, descriptive, retrospective, one-day point prevalence study. Settingintensive care patients hospitalized for a minimum of 24 hours, in 20 Israeli Adult Intensive Care Units, from six medical centers. Main outcome measuresMaximum patient mobility level during the 24 hours prior to the prevalence study collection day and 48 hours from patient admission; mobility clinical practice behaviors and their inhibiting factors. ResultsThe study included 210 patients from a relatively even distribution of admission diagnoses. About half (46%) were intubated and 31% were hemodynamically unstable. Position change was most frequently reported as the maximum mobility level. The use of intubation, ventilation, tracheostomy, and inotropes was positively correlated with the level of mobility. Charlson Comorbidity Index and body mass index were not related to the level of mobility.A multiple regression model including these variables found that only intubation was a significant predictor of mobility level (R2 = 0.52, p < 0.001). ConclusionThere is a gap between clinical practice guidelines and actual intensive care mobility practice behaviors. The association between mobility level and common therapies suggests subjective norms or common practices that could serve as a barrier to guideline implementation and partially explain the gap between clinical practice guidelines and clinical practice behavior. Implications for clinical practiceBehaviors and their subjective norms can be barriers to the implementation of clinical practice guidelines. Promoting increased provider awareness and policies of proactive mobilization could potentially improve patient outcomes.

Risk Factors of Central Line-Associated Bloodstream Infection (CLABSI): A Prospective Study From a Paediatric Intensive Care Unit in South India.

Background Central line-associated bloodstream infection (CLABSI) is the most common hospital-acquired infection. However, studies evaluating the factors associated with the risk of CLABSI in pediatric intensive care units (PICU) were limited in India. Objective The objective of our study is to evaluate the association of factors and the etiologycausing CLABSI. Study design This is a hospital-based single-center prospective study conducted in the pediatric intensive care unit (PICU) of our tertiary care hospital spanning one year. Participants Children aged between two months to 15 years admitted in the PICU for more than 48 hours with central venous catheterization were included. Pearson's chi-squared test with Yates' continuity correction and logistic regression with odds ratio were calculated by R statistical software (RFoundation forStatisticalComputing,Vienna, Austria) and a p-value less than 0.05 was considered statistically significant. Results Our analysis showed that factors such as young age (2-12 months), high pediatric risk of mortality (PRISM III) score (> 15), leukocytosis, neutrophilia, anemia, change of central venous catheter, duration of catheterization (>7 days), exposure to blood products, use of steroids, inotropes, and prophylactic antibiotics were significantly associated with increased risk of CLABSIs with an odds ratio of 4.53, 4.54, 2.91, 4.56, 4.76, 3.74, 2.49, 2.41, 7.22, 6.77 and 5.16 respectively (p<0.05). Further, factors such as older age (>12 months) and low PRISM III score (≤ 15) significantly reduce the risk of CLABSIs by 83.64% and 69.14% respectively (p<0.05). Conclusion In conclusion, our results revealed that factors such as young age, high PRISM III score, leukocytosis, neutrophilia, anemia, change of central venous catheter, duration of catheterization (> 7 days), exposure to blood products during the hospital stay, use of steroids, inotropes, and prophylactic antibiotics were identified as risk factors for CLABSI.

Factors to consider during anesthesia in patients undergoing preemptive kidney transplantation: a propensity-score matched analysis

BackgroundInternational guidelines have recommended preemptive kidney transplantation (KT) as the preferred approach, advocating for transplantation before the initiation of dialysis. This approach is advantageous for graft and patient survival by avoiding dialysis-related complications. However, recipients of preemptive KT may undergo anesthesia without the opportunity to optimize volume status or correct metabolic disturbances associated with end-stage renal disease. In these regard, we aimed to investigate the anesthetic events that occur more frequently during preemptive KT compared to nonpreemptive KT.MethodsThis is a single-center retrospective study. Of the 672 patients who underwent Living donor KT (LDKT), 388 of 519 who underwent nonpreemptive KT were matched with 153 of 153 who underwent preemptive KT using propensity score based on preoperative covariates. The primary outcome was intraoperative hypotension defined as area under the threshold (AUT), with a threshold set at a mean arterial blood pressure below 70 mmHg. The secondary outcomes were intraoperative metabolic acidosis estimated by base excess and serum bicarbonate, electrolyte imbalance, the use of inotropes or vasopressors, intraoperative transfusion, immediate graft function evaluated by the nadir creatinine, and re-operation due to bleeding.ResultsAfter propensity score matching, we analyzed 388 and 153 patients in non-preemptive and preemptive groups. The multivariable analysis revealed the AUT of the preemptive group to be significantly greater than that of the nonpreemptive group (mean ± standard deviation, 29.7 ± 61.5 and 14.5 ± 37.7, respectively, P = 0.007). Metabolic acidosis was more severe in the preemptive group compared to the nonpreemptive group. The differences in the nadir creatinine value and times to nadir creatinine were statistically significant, but clinically insignificant.ConclusionIntraoperative hypotension and metabolic acidosis occurred more frequently in the preemptive group during LDKT. These findings highlight the need for anesthesiologists to be prepared and vigilant in managing these events during surgery.

On-table Extubation After Minimally Invasive Cardiac Surgery: A Retrospective Observational Pilot Study

To assess the safety of "on-table" extubation after minimally-invasive heart valve surgery. A single-center retrospective observational study. At a tertiary referral academic hospital. Patients who underwent nonemergent isolated heart valve surgery through a minithoracotomy approach between January 2016 and August 2021. All patients were treated by 1 of the 6 cardiac anesthesiologists of the hospital. Only some of them practiced "on-table" extubation, and the outcome of patients extubated "on-table" was compared to those extubated in the intensive care unit (ICU). The primary outcome was the occurrence of any postoperative respiratory complication during the entire hospital stay. Secondary outcomes included the use of inotropes and vasopressors, de novo atrial fibrillation, and lengths of stay in the ICU and the hospital. A total of 294 patients met inclusion criteria, of whom 186 (63%) were extubated "on-table." Cardiopulmonary bypass duration was significantly longer, and moderate intraoperative hypothermia was significantly more frequent in patients extubated in the ICU. After adjustment for these confounders and for the European System for Cardiac Operative Risk Evaluation (EuroSCORE) II using a multivariate logistic model, no association was found between the extubation strategy and postoperative pulmonary complications (adjusted odds ratio=0.84; 95% CI=0.40-1.77; p=0.64). "On-table" extubation was associated with a lower risk of postoperative pneumonia and fewer vasopressors requirements. "On-table" extubation was not associated with an increased incidence of respiratory complications. A randomized controlled trial is warranted to confirm these results and determine whether "on-table" extubation offers additional benefits.

A Retrospective Study on Canine and Feline Mortality during Anaesthesia at a University Clinic in Greece.

This retrospective cohort study investigated the mortality rate during anaesthesia and possible contributing factors in canine and feline population in an academic institution in Greece. Data on 1187 dogs and 250 cats which underwent general anaesthesia from 1 January 2018 to 31 December 2019 at the Veterinary Faculty of the Aristotle University of Thessaloniki were analysed regarding cardiac arrest and mortality. In dogs, the rate of cardiac arrest was 1.1% and the rate of death was 0.6%. In cats, these rates were 2.8% and 0.8%, respectively. The mortality rate in healthy/mild disease (ASA I-II) dogs was 0.1% and in cats was 0.5%. Sick (ASA III-V) dogs exhibited a death rate of 2.6%, while sick cats had a rate of 2.2%. In dogs, ASA status had a positive association with cardiac arrest and mortality, with sick dogs being 23 times more likely to suffer cardiac arrest and 24.5 times more likely to die than healthy/mild disease ones. Other factors associated with cardiac arrest and mortality were the anaesthetic protocol and the use of inotropes. In cats, premedication and inotropic support were related to cardiac arrest and death. Feline anaesthesia involves higher risk, and requires greater vigilance in peri-anaesthetic management than dogs.

Incidence of, and Risk Factors and Outcomes Associated with, Acute Kidney Injury in COVID-19 at the National Kidney and Transplant Institute, Philippines.

(1) Background: Acute kidney injury (AKI) in COVID-19 leads to an increase in patient mortality, especially among chronic kidney disease (CKD) patients. (2) Methods: A retrospective cohort of 519 adults admitted from 1 March 2020 to 1 March 2022 were reviewed for baseline characteristics and their association with renal outcomes. Patients were divided into diagnosed CKD, undiagnosed CKD, and normal eGFR. Chronic dialysis and kidney-transplant patients were excluded. Kaplan-Meier survival analysis at 7, 14, and 30 days from admission was performed. (3) Results: The overall incidence of AKI was 45.66%; the proportions among patients with diagnosed CKD, undiagnosed CKD, and normal eGFR were 76.64%, 38.75%, and 7.59%, respectively (p < 0.0001). Multivariate analysis showed that being male and inotrope use were significant risk factors for AKI, while higher eGFR was protective. AKI was associated with dialysis, invasive ventilation (p < 0.0001), prolonged hospitalization (p = 0.0001), and mortality (p < 0.0001). Renal recovery was 64%, 59%, and 23% in stages 1, 2, and 3 AKI, respectively, until 14 days from discharge (p < 0.0001). Patient survival was lower in cases of AKI: 83.16%, 70.59%, and 47.5% compared to non-AKI figures of 91.27%, 87.82%, and 76.95% at 7, 14, and 30 days respectively(p = 0.0001). (4) Conclusion: There was a higher incidence of AKI with worsening renal function. Intensified preventive measures for AKI are crucial to prevent its devastating consequences.

Hemodynamic and Management Perspectives in Heart Failure Patients

Introduction Prevalence of heart failure (HF) is increasing, and right ventricular (RV) dysfunction is an independent predictor of mortality. Accurate echocardiographic evaluation of RV function is challenging and novel parameters which can aid in prediction RV function are required. Pulmonary artery Pulsatility index (PAPi) is one such parameter. Patients and Methods We conducted a prospective study in 33 patients admitted with symptoms of HF and severe LV dysfunction (EF &lt; 35) who underwent right heart catheterization and followed them for 6 months. Primary objective was to determine the association of PAPi with hospitalizations and mortality in short-term follow-up in HF patients. Clinical, demographic, echocardiographic, and catheterization data were recorded. PAPi was calculated as a ratio of pulmonary artery pulse pressure and right atrial pressure. Results The mean age of population was 47 years (±12). Males were 20(61%) and females were 13(39%). Median PAPi in the study population was 2.42 (IQR-1.83). The study population were stratified into 3 groups based on 10th, 50th, and 90th percentile PAPi and on comparisons between groups PAPi was significantly associated with hospitalization at 1 and 6 months in univariate ( P = .03 and P = .03 respectively) and in multivariate analysis ( P = .04). PAPi was not found to be associated with mortality at 1 month or 6 months. However, the absolute mortality was low in the study population (n = 4). Conclusion PAPi has been found to be a strong and an independent predictor of hospitalization at 1 month and 6 months. Comments Advanced HF is seen in 1 out of 5 patients with HF. It is characterized by refractory symptoms, multiple hospitalizations, fluid retention, elevated natriuretic peptides, and decreased cardiac output often requiring inotropes. The survival rate is poor. The presence of right ventricular dysfunction is an independent predictor of mortality in these patients. Hemodynamic assessment is of importance in these patients to guide regarding further management, ie, use of inotropes, left ventricular assist devices, etc. The PAPi is a marker derived from the formula (PASP-PADP/RAP). 1 The outcome worsens as the PAPi decreases. However, the stroke volume, pulmonary artery capacitance (PAC), and right atrial pressure all have an impact on PAPi. Patients with high PAC will have better PAPi compared to those with low PAC with the stroke volume being constant. 2 Different subsets of HF population have varying PAPI thresholds, with isolated RV infarction having the lowest (0.9) and severe HF having the highest (3.2). 2 Future research should examine the impact of exercise, inotropes, and vasodilators.

State of Shock: Contemporary Vasopressor and Inotrope Use in Cardiogenic Shock.

Cardiogenic shock is characterized by tissue hypoxia caused by circulatory failure arising from inadequate cardiac output. In addition to treating the pathologic process causing impaired cardiac function, prompt hemodynamic support is essential to reduce the risk of developing multiorgan dysfunction and to preserve cellular metabolism. Pharmacologic therapy with the use of vasopressors and inotropes is a key component of this treatment strategy, improving perfusion by increasing cardiac output, altering systemic vascular resistance, or both, while allowing time and hemodynamic stability to treat the underlying disease process implicated in the development of cardiogenic shock. Despite the use of mechanical circulatory support recently garnering significant interest, pharmacologic hemodynamic support remains a cornerstone of cardiogenic shock management, with over 90% of patients receiving at least 1 vasoactive agent. This review aims to describe the pharmacology and hemodynamic effects of current pharmacotherapies and provide a practical approach to their use, while highlighting important future research directions.